Development of a Multinational Collaboration Supporting Reconstructive Surgery in Response to the 2023–2025 War in Gaza

Abstract

Background:

The escalation of conflict in Gaza since October 2023 has devastated an already fragile healthcare system and generated an overwhelming civilian need for reconstructive surgical care. Traditional humanitarian approaches often defer reconstructive planning until conflict resolution, which delays care and worsens morbidity. The global plastic and reconstructive surgery community has extensive experience in collaboration, but few published models exist for the proactive formation of ethically grounded, multidisciplinary teams during active conflict.

Methods:

We used a community-based participatory research framework to establish a multinational, multidisciplinary team focused on reconstructive surgical planning in Gaza. The team included academic plastic surgeons, clinicians with relevant geographic experience, implementation scientists, and regional scholars. We prioritized early engagement of Gaza-based partners and institutional review board approvals from relevant Palestinian entities to ensure contextual relevance.

Results:

Within 1 year, we established a functional, ethically approved collaboration with institutional funding and administrative support. Key lessons included the importance of early stakeholder engagement, leveraging short-term goals for long-term progress, adapting to dynamic conflict conditions, establishing internal infrastructure, and maintaining flexible communication channels. The first wave of initiatives focused on actionable outputs is underway, including estimating reconstructive surgical need, conducting capacity evaluations, and documenting current care delivery.

Conclusions:

Our approach offers a replicable, ethical framework for context-sensitive collaboration in conflict zones. It enables plastic surgeons to engage proactively in humanitarian crises beyond direct care. Actionable outputs can be used by local leaders, organizations, and policymakers to reduce delays between conflict resolution and delivery of reconstructive care.

Takeaways

Question: The war in Gaza has created an immense need for reconstructive surgery—can we assist beyond direct surgical care?

Findings: We built a multinational, multidisciplinary team using a community-based participatory research approach. Collaboration with regional stakeholders ensured ethical research and actionable insights. Key lessons included flexible communication, stakeholder engagement, logistical foresight, adaptability, and short-term goals for sustainability.

Meaning: Our replicable approach, enabling remote participation by plastic surgeons, accelerates reconstructive care following conflict by producing actionable outputs for local healthcare leaders, policymakers, and organizations.

INTRODUCTION

The ongoing war in Gaza has severely compromised an already strained healthcare system and increased the need for surgical care.^1–3 During the acute phase of conflict, this need has centered on life-saving measures. Experience from prior conflicts has shown that after the acute phase, a significant reconstructive surgical need invariably emerges.^4–7 Modern urban conflict creates a large civilian burden of burns, limb injuries, craniofacial injuries, and soft-tissue defects. The treatment of these injuries requires reconstructive expertise, underscoring the direct connection between conflict-related morbidity and the core skill set of reconstructive surgeons. Traditionally, relief efforts during wartime focus on immediate medical care, and data collection that can guide the establishment of adequately resourced reconstructive surgery is deferred until the conflict subsides, significantly delaying the delivery of reconstructive treatment. The field of plastic and reconstructive surgery has extensive experience in establishing multinational collaborations on a wide range of issues, from congenital craniofacial deformities to specialized microsurgical training.^8–10 However, to our knowledge, limited published experience exists on forming a multinational, multidisciplinary team to study and plan for emerging reconstructive surgical needs during an active conflict.

This style of work has been well documented in other specialties and topics and is frequently approached via a community-based participatory research (CBPR) model (Fig. 1).¹¹ CBPR addresses key challenges that traditional translational and clinical research methods neglect, especially when the work involves marginalized populations or includes transnational health projects. Wallerstein and Duran¹¹ detailed the 6 core challenges of translational research: external validity, the privilege of academic knowledge, language barriers between academia and the community, business as usual within the university, nonsustainability, and lack of trust. Table 1 highlights the ability of a CBPR model to address each of these core challenges in the context of supporting reconstructive surgery needs in Palestine.

Fig. 1.

Schematic highlighting the CBPR methodology, adapted and tailored to our work focused on meeting the need for reconstructive surgery in a conflict setting. Adapted from Wallerstein and Duran.¹¹

Table 1.

Outline of Core Challenges Faced in Traditional Translational Research Methodologies, and the Specific Elements of CBPR Methodology That Address Those Challenges

Challenge Faced in Translational Research Methodology	Specific Elements of CBPR Methodology to Address Challenges
External validity	• Design of project in conjunction with local stakeholders • Collection of new data within the region • Incorporating frequent updates to methodology and approach as the conflict and situation change
Privilege of academic knowledge	• Shared knowledge creation and thought partnership • Collaborative design and execution of research initiatives
Language rooted in power differentials between academia and the community	• Shared authorship in the creation and dissemination of output • Frequent communication across team members to ensure project approaches are appropriate
Business as usual within the university	• Reallocation of decision-making from traditional “academic” personnel to project leadership globally • Sharing of resources, data, and findings across team members
Nonsustainability	• Establishment of renewable long-term funding • Incorporation and support of junior team members within the region
Lack of trust	• IRB approval from the academic university and relevant authorities within the region • Continued and meaningful engagement of stakeholders with experience in the region

We believe that in addition to the actual delivery of reconstructive care, members of the plastic surgery community can play a larger role in guiding, planning, and supporting the overall delivery of reconstructive care in conflict settings. To test this, we assembled a multinational, multidisciplinary working group to proactively address reconstructive surgical needs during the ongoing conflict in Gaza. Specifically, our approach asked 2 questions: (1) can a CBPR approach overcome logistical difficulties and be applied during an active conflict, and (2) can such an approach isolate actionable findings with regard to reconstructive planning? Here, we present our preliminary experiences with the intent to share a framework that can be extrapolated to support the timely delivery of reconstructive care in other conflict settings.

CONTEXT

Unlike other conflicts in which military personnel have borne the brunt of morbidity and mortality, the mechanisms of warfare used by Israeli forces during the most recent escalation of hostilities since October 2023 have disproportionately affected Palestinian civilians and severely impacted Palestinian healthcare personnel.^12–14 This exacerbates an already large need for reconstructive care that was present before the increase in hostilities and is a need that is unmet by a healthcare infrastructure underresourced at baseline, especially with regard to plastic and reconstructive surgery.¹⁵

Many hospitals have ceased to function or are operating at severely diminished capacity due to structural damage and limited personnel.^15–18 Systemic issues, such as power outages, a lack of clean water, and breakdowns in the supply chain due to blockades of aid deliveries, have resulted in nonfunctional operating theaters and increased wound complications.^15,19 As a result, the ability to provide reconstructive care has been severely diminished. According to the Ministry of Health in Gaza and the United Nations Office for the Coordination of Humanitarian Affairs, an estimated 132,239 individuals have been injured, and 56,156 individuals have died between October 7, 2023, and June 25, 2025, in the Gaza Strip, with numbers continuing to rise as the war progresses and additional bodies are found.²⁰ Independent academic studies suggest these estimates undercount the rates of Palestinian morbidity and mortality, with more than 64,000 deaths calculated from October 7, 2023, to June 30, 2024, alone, and a substantial portion of these injuries will warrant reconstructive care.^15,21,22

This creates a challenge that extends beyond immediate surgical intervention. Effective reconstructive surgery requires prolonged follow-up, rehabilitation, and secondary procedures—services that are currently inaccessible to many due to mass displacement and security concerns. Significant numbers of healthcare workers have been killed in the conflict, further exacerbating the shortage of trained specialists.^15,23 According to a recent study by Alser et al,¹⁵ in February 2023, there were 3 board-certified plastic surgeons in Gaza and no plastic surgery residents or training program. Additionally, cross-border evacuations for complex medical cases have become nearly impossible due to Israeli border closures, leaving thousands of injured civilians and those with chronic medical conditions without access to necessary care.

Many global medical workers, including reconstructive surgeons, risk personal safety to provide care amid the active conflict. However, effectively addressing the total burden of reconstructive need requires relative stability and a comprehensive understanding of the scope and scale of need. This includes clarifying the nature and volume of specific injuries, evaluating the care received during the active conflict, and identifying the infrastructure, equipment, and personnel required for subsequent phases of reconstructive care.

PARTNERSHIP PROCESSES

To minimize institutional and national bias, we prioritized the selection of partners and leaders from multiple academic institutions and countries; to address bias of thought, we sought individuals with varied research and clinical experiences, and to ensure actionable work, we ensured the early involvement of Palestinian surgeons from the region and individuals with relevant recent clinical experience in the region. Partners and team leaders were found via referrals from thought leaders in the field and by direct contact with individuals well known for their experience and work. Our decisions were partially limited by the number of individuals with relevant experience who were able to commit to the project. Final leadership included academic surgeons (A.P., P.N.H.), former head of plastic surgery at Al-Shifa (A.M.), surgeons with extensive experience in the region (V.R., A.M.), an ethnographic social scientist of the region and its healthcare system (F.H.), and an implementation and global health scientist (C.S.). To prevent the siloing of expertise, leaders collaborated across subgroups, applying their skills as needed (Fig. 2).

Fig. 2.

Structure of a multidisciplinary team. A multidisciplinary team can be set up with each subgroup siloed based on expertise (A), or with each subgroup structured around a specific category of problem (B). When structuring around a problem, junior team members are pulled from various backgrounds, and senior leadership of all expertise contribute to the overall guidance of the problem.

The proposal was written by a combination of the listed authors and developed in conversation with plastic surgeons who had experience in the region. In addition to procuring institutional review board (IRB) approval from the Duke School of Medicine (IRB 00116798), the project was also approved by the Helsinki Ethics Committee of the Palestinian Health Research Council (PHRC/HC/1734/24), the relevant authority where significant portions of field research would be conducted. These approvals encompassed the project in its entirety. The partnership received institutional funding, infrastructure, and staffing in August 2024 through the Duke Bass Connections program, which also facilitated the incorporation of undergraduate students and managed logistical support (Fig. 3).²⁴

Fig. 3.

High-level timeline highlighting key stages of project planning and research execution.

Given the sensitive nature of healthcare data from an active conflict zone, data protection was prioritized. All identifiable information was stored on Health Insurance Portability and Accountability Act–compliant, password-protected secure servers. Communication was done over encrypted platforms, and access was limited to research personnel on the team.

INTERVENTION AND RESEARCH

Intervention and research in the CBPR model are adapted to the region, reflect reciprocal and bidirectional learning, and use an effective and appropriate research design. Shared decision-making involving all partners was critical when designing the objectives of our project. Ultimately, we aligned on 3 key initiatives: (1) forecasting the reconstructive need in Gaza at a granular level through a computational modeling approach, (2) developing a granular surgical capacity evaluation tool to assess readiness at a systems level for performing specific types of reconstructive surgery, and (3) documenting the existing infrastructure and state of care delivery amidst the ongoing conflict. This project design, with 3 actionable specific outputs to be largely completed by the end of the academic year, was intentional. It allowed us to structure goal-oriented subgroups with clear tasks and objectives. Subgroups, each composed of 4–5 undergraduate students, followed structured timelines from initial readings to iterative design, data collection, and write-ups (Fig. 3).

OUTCOMES

Our collaboration successfully answered our first research question of whether a CBPR approach can overcome logistical difficulties and be applied during an active conflict. We measured progress against specific process indicators of success that spanned the stages of the CBPR methodology, including in the partnership process stage (securing initial funding, ethical research approval, attendance at team meetings, engagement of leadership and stakeholders), in the intervention and research stage (successful short-term analytical outputs, funding renewal, and individual team member growth), and in the outcome stage (evidence of bidirectional learning, sustained partnership, and academic dissemination of findings). Although these indicators do not encompass all facets of the CBPR methodology or the project, they provided goalposts to keep the work aligned with intended objectives and helped inform the team when course correction was necessary. Taken together, these indicators show overarching success (Table 2).

Table 2.

Process Metrics and Indicators of Success Used to Assess Progress Throughout the Course of the Collaboration

Stage	Process Metric	Degree of Success	Brief Rationale (Further Detail in “Key Lessons” Section of the Article)
Partnership process	Initial funding	High	Grant funding successfully met all anticipated budget needs
	Ethical research approval	High	Ethical approval for research by multiple institutional review boards
	Team meeting attendance	Medium -> high	Attendance improved with the transition to synchronous hybrid meeting formats
	Engagement of leadership and stakeholders	Medium	Communication was at times difficult due to team members working across time zones and in an active conflict zone, but was maintained through flexible multimodal communication channels
Intervention and research	Successful short-term analytical outputs	Medium -> high	Data availability and unpredictability initially slowed research progress but was overcome by staying adaptable and improvising
	Funding renewal	High	Continued funding for the collaboration was secured by demonstrating completion of short-term goals and outputs
	Team member growth	High	Individual reflections helped ensure team members were cognizant of underlying power imbalances and ethical issues that are present in all global health work and helped provide an avenue for feedback regarding how the team was functioning and areas for improvement
Outcomes	Evidence of bidirectional learning	High	As evidenced in individual reflections and during team meetings, learning was not unilateral. Rather, all team members benefited from the unique experiences and perspectives of each other
	Sustained partnership	High	Partnership remained intact through the course of the project, allowing time for prolonged work on multiple research topics and the ability to generate and explore new ideas
	Academic dissemination of findings	Ongoing

A detailed description of the output of our collaboration is beyond the scope of this article and will be shared as individual outputs are finalized. In brief, we have been able to make substantial progress along all research initiatives, which include an injury forecasting model, a Delphi methodology–validated capacity evaluation tool, and ongoing documentation of healthcare delivery in Gaza. The goal of this work was to improve outcomes and enact change, but it was too early to assess success beyond initial outputs. Once we reach the later stages, we will be more confidently able to address the second research question of whether our approach can isolate actionable findings.

KEY Lessons

Key lessons were derived from team-wide evaluations and monthly progress assessments. Recurring themes and the efforts taken to address them are presented in the following sections.

The Importance of Frequent and Flexible Communication

Frequent, flexible communication proved to be critical. Communication gaps caused duplicated effort, missed deadlines, and left undergraduate team members feeling siloed from the larger goals.

To improve communication between subgroups, we switched from virtual asynchronous meetings to a synchronous hybrid format, which increased meeting productivity and streamlined team collaboration. We also became more fluid in our communication channels by heavily relying on secure audio and text messaging to facilitate ease of response, particularly as we are a multinational group working across multiple time zones and intermittently within conflict areas.

Early and Continued Engagement of Stakeholders

Engagement of Palestinian stakeholders from the beginning of the initial project conception was fundamental. Ensuring the involvement of key stakeholders is a core tenet of a CBPR model for many reasons, including reducing the risk of operating in a silo, providing key context, ensuring appropriate research design, and facilitating bidirectional learning. Their presence enriched the learning environment, offering early-career students direct insight into applied research and operational realities.

In addition, a leadership team that included individual stakeholders with experience working in Gaza lent our project credibility for engagement with institutional stakeholders, such as the Palestinian Health Research Council. At its core, the goal of the project was to support reconstructive surgery in the region. Without active engagement from individual and institutional stakeholders in Palestine, this project would be an academic exercise whose research and measurement outcomes primarily benefit the careers of professionals and scholars based in the West. Academically fascinating results would not necessarily be actionable in the service of rebuilding and improving healthcare in Gaza. Actionability is a critical component of any implementation science work and was a key request made by our stakeholders, which we prioritized in our project.

Keeping Ahead of Logistics

A significant amount of upfront and ongoing effort was consumed by addressing the logistical infrastructure of the project. This included the initial grant proposal and a successful request to renew the project for a second year, designing a course structure and syllabus to allow for the involvement and contributions of undergraduate and graduate students, setting up centralized online file-sharing systems, frequent oral and written evaluations for undergraduate researchers, scheduling and organizing meetings well in advance to ensure attendance, and applying for institutional IRB and ethics approval in 2 settings. This infrastructure enabled the team to pursue multiple simultaneous workstreams and stay focused on the project’s aims rather than internal problems.

Staying Adaptable and Improvising When Necessary

Conflict settings are inherently unpredictable, requiring high adaptability, flexibility, and resourcefulness. Data reliability can fluctuate significantly, and geopolitical shifts or intensified conflicts frequently disrupt data collection and project planning. As circumstances evolve, project objectives must be continually reassessed for relevance. For instance, the ongoing destruction of Gaza’s healthcare infrastructure forced us to modify our methods for assessing local reconstructive capabilities. Systematic targeting has left critical healthcare facilities and the overarching governance body of the Ministry of Health barely operational. Consequently, many hospital records have been lost or destroyed, and remaining healthcare staff work under dire conditions that severely limit record-keeping and documentation.^25,26 The few international organizations still active in Gaza face severe operational constraints, limiting the availability and comprehensiveness of their data and necessitating supplementary data collection. However, conducting on-the-ground surveys required frequent pauses due to ongoing bombardments and shifting conflict zones. Regular communication between project leadership and subgroup members allowed timely adaptations to our research methods and effective improvisation.

Leaving Room for Idea Generation and Exploration While Staying Focused

As each initiative progressed, new ideas consistently emerged—some directly related to ongoing tasks, others branching into broader areas. Some of these ideas warranted immediate exploration, whereas others were deferred until primary goals were achieved. Ideas came from every level of our team, from junior members to senior leaders, underscoring the importance of maintaining an environment that encouraged open sharing and merit-based discussion. We regularly documented and reviewed these ideas during team meetings and via email, enabling us to track both short-term opportunities and long-term possibilities. However, recognizing when a team was stuck or unproductively revisiting an idea was also essential. To ensure productivity, we frequently restated overarching goals, emphasized the broader project context, encouraged analytical writing, and set clear short-term targets. Additionally, regular communication with the broader team—who were less involved in day-to-day subgroup activities—allowed for external perspectives on progress and challenges. This balanced approach ensured continuous progress toward our main objectives while maintaining space for creativity and exploration.

Short-term Goals Can Sustain Long-term Sustainability

Achieving the broad goals of this type of project requires more than a singular academic output. It requires the establishment of a collaborative group and sustained work over the course of years. Extending the timeline gave the team flexibility to address problems effectively rather than rushing solutions. In addition, as certain regions have experienced a partial reduction in hostilities, we have been able to start equipping junior team members within Gaza with the equipment and support to collect and analyze data. The renewal of funding for a second academic year enabled us to maintain a long-term perspective and build on outputs and achievements from the first year. Our ability to secure continued funding was bolstered by an iterative approach of frequent synthesis and write-ups of findings that showed progress in a short period, the effective establishment of a multinational collaborative with multiple IRB approvals that highlighted our ability to conduct meaningful and ethical work, and a grasp of the logistics of project management, which maximized efficiency while maintaining team engagement.

Frequent Assessment of Partnership and Reflection

It is important to recognize that in any global health setting, there is an inherent power imbalance amplified by available resources, safety away from active conflict, and historical contexts. Our tangible approaches to mitigate this power imbalance included equal data access, shared authorship, ensuring that the analysis was accessible to all members of the team as it was performed, and intentional bidirectional learning. In addition, all junior members of the team performed biannual self-reflections incorporating their individual contributions, learning, and discussion of the aforementioned nuances of conducting research in a global health setting.

CONCLUSIONS

We described here our experience of building a multinational, multidisciplinary collaborative team, with the goal of supporting efforts that meet the need for reconstructive surgery in an active conflict setting using a CBPR approach. Partnering with stakeholders in the region, this approach can provide insightful and actionable findings, ensure that research is conducted in an ethical manner, establish trust across communities, and build a platform for sustained progress. In addition, it is designed to provide valuable insights for governments, aid agencies, nongovernment organizations, and local organizations for advocacy and resource planning. Ultimately, our goal is to shorten the delay between resolution of the active conflict and the ability to meet the reconstructive need, and to provide avenues for physicians and individuals from various backgrounds to help without traveling to the region to directly provide care.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article.

This work was funded by the Duke Bass Connections Program.

ACKNOWLEDGMENTS

This work would not have been possible without the contributions of students in Gaza and the United States, listed below. Gaza-based team: Osama Sweid, Loay Kanou, Hamza Abu Daqqa, Hadeel Abu Daqqa, Rozan Abu Amona, Ruba Musallam, Rahaf Abu Daqqa, Sondos Abu Daqqa, Huda Al Khalidi, and Abdelrahman Al-Najjar (posthumous; killed during active conflict in Gaza). United States–based team: Oumaima Berrada, Isha Chugh, Jakaiyah Franklin, Ethan Grimminger, Cooper Ruffing, J. Shoemaker, Muskaan Toshniwal, Megan Bonne, Rohil Watwe, Stephen Harris, and Emily Song.